Dispesing

DISPENSING AND STORAGE OF MEDICINES
POLICY
This is a working document and any changes that become necessary to this policy
must be notified in writing to the Medicine Management Group via the Chief
Pharmacist, East Cheshire Trust
THIS POLICY MUST BE READILY ACCESSIBLE AT ALL TIMES AND AT

THE POINT WHERE MEDICINES ARE USED.
The Medicines Management Group

Version 2.0 February 2017
Review: December 2019
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Policy Title: Dispensing and Storage of Medicines Policy
Executive This policy provides guidance to all staff in East Cheshire

Summary: NHS Trust regarding all aspects of the dispensing and
storage of medicines.
Supersedes: Version 2.0 Dispensing and Storage of Medicines Policy

Description of No major amendments
Amendment(s): Inclusion of required actions during fridge temperature
deviations (December 2017)
This policy will impact on:

All health professionals involved in the prescribing, supply, administration and
handling of medicines
Financial Implications:
Financial impact to release staff time to address training needs.
Policy Area: Medicines Document ECT002709

Management Reference:
Version Number: 2.1 Effective Date: December 2017
Issued By: Chair of Medicines Review Date: December 2019
Management Group
Author: Chief Pharmacist Impact December 2016
Assessment Date:
APPROVAL RECORD
Committees / Group Date
Consultation: Management – clinical and February 2017
associate directors
Specialist Advice (if February 2017
required)
Pharmacists, Lead nurses /
matrons, consultants
Other (please specify) February 2017
Medicines Management Group (Update approved
December 2017)
Approved by Director: Medical Director February 2017
Director of Nursing,
Performance & Quality
Received for information: Trust SQS Committee February 2017
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POLICY FOR THE DISPENSING AND STORAGE OF MEDICINES
Table of Contents
1 INTRODUCTION ................................................................................................. 4
1.1 Policy Statement ................................................................................................ 4
1.2 Definitions.......................................................................................................... 4
1.3 Organisational Responsibilities ......................................................................... 4
1.4 Planning and Implementation ............................................................................ 5
1.5 Measuring Performance ..................................................................................... 6
1.6 Legislation.......................................................................................................... 6
1.7 Audit .................................................................................................................. 6
1.8 Review ............................................................................................................... 6
1.9 Training .............................................................................................................. 6
1.10 Dignity, Equality and Diversity ......................................................................... 7
2. DISPENSING AND SUPPLY OF MEDICINES .................................................. 7
2.1 Medicines Supply............................................................................................... 7
2.2 Use of patient’s own medicines ......................................................................... 9
2.3 Dispensing & Supply of Chemotherapy .......................................................... 10
2.4 Transport and receipt of medicines .................................................................. 10
2.5 Supplying medicines for patients to use outside hospital ................................ 11
2.6 Supply of medicines to clinical areas when pharmacy is closed ..................... 13
2.7 Specific considerations for paediatrics ............................................................ 16
2.8 Dispensing/ Supply Medicine Errors ............................................................... 16
3. STORAGE & SECURITY OF MEDICINES...................................................... 17
3.1 Introduction ..................................................................................................... 17
3.2 Storage & Security of medicines within clinical areas ................................... 17
3.3 Patients Own Medicines ................................................................................. 21
3.4 Mediwell Cabinets .......................................................................................... 21
3.5 Keys ................................................................................................................ 22
3.6 Controlled Drugs & Illegal or suspicious substances ..................................... 23
3.7 Missing medicines .......................................................................................... 23
3.8 Controlled Stationery ...................................................................................... 23
Appendix one ............................................................................................................... 25
Appendix two ............................................................................................................... 30
Appendix three ............................................................................................................. 33
Appendix four .............................................................................................................. 34
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1 INTRODUCTION
1.1 Policy Statement
1.1.1 The prescribing of medicines for patients is the most common intervention
made as part of the treatment provided to patients during a hospital
admission. This policy is for the use of all staff who involved in the
management of medicines as part of their duties as an employee of East
Cheshire NHS Trust. This policy must be complied with. If there is any cause
for concern with respect to medicines usage in any area, staff are
encouraged to contact the Chief Pharmacist.
1.1.2 The purpose of this policy is to:
 Provide guidance to all Trust staff on the procedures relating to

the dispensing, safe and secure handling and storage of
medicines.
 Avoid patients, staff and visitors being put at risk as a result of the
incorrect handling of medicines.
 Ensure all legislation and guidance is adhered to with respect to
medicines.
 Provide robust systems for storing, supplying, transporting, of
medicines.
1.2 Definitions
1.2.1 Medicines Management
Medicines Management in hospitals encompasses the entire way that

medicines are selected, procured, delivered, prescribed, administered, and
reviewed to optimise the contribution that medicines make to producing
informed and desired outcomes of patient care (Audit Commission 2001).
1.2.2 Registered Nurse
Throughout this policy a registered nurse is taken to mean any nurse,

midwife and specialist community public health nurses who are registered
with the NMC (http://www.nmc-uk.org/Registration/Useful-information/Registration-
qualifications/)
1.3 Organisational Responsibilities
1.3.1 Chief Executive

Has ultimate responsibility for the implementation and monitoring of the
policies in use in the Trust. This responsibility may be delegated to an
appropriate colleague.
1.3.2 Medical Director
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Has Trust Board responsibility for all aspects of medicines management. The
Medical Director is responsible for reporting any medicines management
issues identified to the Trust Board.
1.3.3 Chair of Medicines Management Group

The Chair of the Medicines Management Group has responsibility for co-
ordinating the activities of the Medicines Management Group to ensure that
good practice relating to medicines, as described in this policy, becomes
embedded in to everyday working practice across the Trust. The Chair will
raise any medicines management issues at the Trust SQS Committee.
1.3.4 Chief Pharmacist

The Chief Pharmacist has responsibility for ensuring the Trust complies with
local and national guidance relating to medicines, and to ensure the Business
Units are fully informed of their role in maintaining the required standards of
practice relating to medicines.
1.3.5 Directorates
It is the responsibility of the Clinical Directors and Associate Directors to
ensure that all staff are trained to carry out the tasks required of them in the
prescribing, administration and management of medicines.
1.3.6 Ward / Department Managers

Responsibility for the operational implementation of the Medicines Policy,
including ensuring staff within their ward / department attends appropriate
training.
1.3.7 Pharmacy Staff

Responsibility for; providing information and advice to Trust personnel on the
handling and storage of medicines used within the Trust, assisting where
appropriate in formulating local procedures at ward/departmental /business
unit level, ensuring that the laws relating to the safe and secure handling and
storage of medicines are complied with.
1.3.8 All staff

Are responsible for attending appropriate medicines management training
and following guidance set out in this Policy.
1.4 Planning and Implementation
 This policy has been circulated to the clinical directors and matrons for
comment
 The policy will be approved by the Medicines Management Group (MMG).
 The policy will be uploaded onto the Trust internet and an email
containing a link to the policy will be sent to all staff.
 It is the responsibility of the ward and department managers to inform
their staff of the changes in the policy.
 All staff groups involved in the management of medicines should receive
training related to medicines management. The training should be tailored
to the requirements of the staff group involved.
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1.5 Measuring Performance
The Trust may be measured for compliance with NHSLA standard C4 criteria
6, and by the Care Quality Commission
1.6 Legislation
This policy complies with all relevant legislation and guidelines that are
considered to be good practice which relate to the prescribing, supply,
storage, security and administration of medicines.
1.7 Audit
East Cheshire NHS Trust recognises its responsibility to check practice in

adherence to all trust policies including ‘The Safe and Secure Handling of
Medicine Policy’ through audit. Aspects to be audited as part of a rolling audit
programme should include:
Storage and security of There will be rolling audits to assess

Medicines safety and security of medicines on the wards
All audits should be registered with the Trust Department for Clinical
Effectiveness. Audit results should be discussed by the Medicines
Management Group to identify areas of good and poor practice, and to
highlight training needs.
A Medicines Management report will be submitted to the Trust SQS

Committee annually.
1.8 Review
It is the responsibility of the Medicines Management Group to review and

amend this policy. This policy will be reviewed and up-dated every 2 years.
The review of the policy will include feedback from the performance review,
audit and training related to the policy.
1.9 Training
All staff groups involved in the management of medicines should receive

training related to medicines management. The training should be tailored to
the requirements of the staff group involved. Aspects of training should
include:
 All groups of staff involved in the management of medicines should

receive a medicines management training session as part of their
induction
 Training specifically for medical staff should include sessions about
various aspects of medicines management - delivered as part of the
F1/F2 training programme
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 Training specifically for nursing staff should include: a training session
and assessment for all nurses before undertaking administration of
intravenous drugs
 Training specifically for pharmacy staff should include: completion of a
postgraduate certificate / diploma in clinical pharmacy for junior grade
pharmacists; minimum of NVQ 2 Pharmacy Services for all Technical
Staff as well as the completion of registration qualifications for ALL
Pharmacy Technicians. This may be supplemented by attendance of in-
house and external training sessions for all pharmacy staff.
 Training specifically for non-medical prescribers: completion of level 3 / 4
Non-Medical Prescribing Course prior to commencing supplementary /
independent prescribing
The objectives and contents of all in-house medicines management training

should be discussed and approved by the Medicines Management Group.
Training needs specifically tailored to individuals, or departments, may be

identified following a review and identification of trends from the Trust Drug
Incident Reporting scheme.
1.10 Dignity, Equality and Diversity
This policy has been impact assessed with regards to dignity, equality and
diversity with respect to patient’s age, choices, lifestyle and cultural / religious
beliefs (see appendix one)
2. DISPENSING AND SUPPLY OF MEDICINES
2.1 Medicines Supply
2.1.1 All medicines for use within the hospital must be supplied through the Trust
pharmacy department. Patient’s own medications validated as suitable for
administration may also be used. Pharmacy staff are responsible for the safe
and effective procurement of all medicines to be used in the Trust.
2.1.2 It is not acceptable for staff to acquire medicines directly from

companies/company representatives – this includes sample products
2.1.3 Medicines supplied by the Trust pharmacy department must not be used for
the treatment of anyone other than Trust patients currently undergoing an
episode of care. They are not to be used for the treatment of relatives or
friends of the patient or for the treatment of hospital staff. The Pharmacy
Department operates a Pharmacy shop where staff, relatives and patients
may be able to purchase some over the counter medications if appropriate.
2.1.4 Medicines Supply – Ward Stock
2.1.4.1 Each clinical area will have a range of medicines which are kept as stock.
The pharmacy department and the manager of the clinical area will determine
the list of stock items.
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2.1.4.2 Ward stocks are topped up regularly by pharmacy staff. The frequency and
day of the “top up” is agreed after discussion with the ward manager and
pharmacy.
2.1.4.3 If stock levels of a medicine are low, the nurse should firstly liaise directly
with their ward based team to arrange urgent stock replenishment. If the ward
based team is unavailable the nurse should leave a message on the
pharmacy stores telephone answering machine (Ext 1565). Paper-based
ordering systems are available (e.g. the ward pharmacy diary or the ward
medicines requisition book); however these should not be relied on if ward
stock is urgently needed.
“At risk medicines” – Diazepam/Codeine Phosphate/Co-codamol may only be

ordered for stock when a paper requisition is written. Paper-based
requisitions should be complete, legible and signed, and then sent to the
pharmacy department.
2.1.4.4 Wards/ clinical areas using Mediwell 365 cabinets will have orders
transmitted automatically to Pharmacy on a daily basis, as stock is used.
These orders will be accessed by the Pharmacy team and replenished back
to the Mediwell cabinets on agreed days of the week.
2.1.4.5 Some clinical areas order their own stock medicines from an agreed stock
list. These areas will receive their stock on the agreed day(s) of the week.
2.1.4.6 For the supply of controlled drugs as stock, please refer to the Trust Policy
on the Safe and Secure handling of Controlled Drugs.
2.1.4.7 Stock items will not routinely be supplied at the weekend or out of hours,
except for clinical urgency.
2.1.5 Medicines Supply – Non-Stock
2.1.5.1 Wards should liaise directly with the ward based Pharmacy team, who will
raise the order as an electronic Ward one stop request from the ward. This
will be transmitted to the Pharmacy Dispensary and dispensed, checked
and then transported back to the ward. Urgently required items can be
electronically tagged to provide communication to the Pharmacy Dispensary
as to their urgent need
2.1.5.2 For the supply of medicines to wards without a clinical (ward) pharmacist, in
urgent circumstances and at weekends, the inpatient medicine chart must
be sent to pharmacy along with a Pharmacy requisition clearly identify what
medicines are required. The inpatient medicine chart must have all the
relevant details completed accurately, including the current ward and
consultant.
2.1.5.3 It is vital that if more than one chart is in use that ALL charts are sent to
pharmacy to enable an appropriate clinical assessment to be made.
Medicines required for discharge within a blister pack must be requested
only after an assessment has been completed to ensure stability of the
medicines and suitability of the patient for such a device.
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2.2 Use of patient’s own medicines
2.2.1 It is the policy of East Cheshire NHS Trust that on admission to hospital,
patients are asked to bring their own medicines with them. Medicines brought
in by patients should only be used within the Trust when they can be
positively identified. Medicines will be assessed as per the Trust Procedure
for the Assessment of Patient’s own Medicines for use in the Hospital by
pharmacy staff at the earliest opportunity.
2.2.2 Patients’ own medicines used in the Trust must be prescribed on the inpatient
medicine chart.
2.2.3 A pharmacist or a trained pharmacy technician must assess patients’ own

medicine for its suitability for use.
2.2.4 Out of hours, a registered nurse may complete the assessment of a patient’s
own medicine for administration against a valid prescription against the critera
in 3.2.6 below. If a nurse has made this assessment a pharmacist or trained
pharmacy technician must assess the medicine at the next available
opportunity.
2.2.5 Patients own medicines, to be administered by staff in the community should

also be assessed, using the criteria below (3.2.6), to ensure they are
appropriate to use.
2.2.6 Assessment of patient’s own medicines must comply with the following:
 Visibly intact, clean packaging

 Clearly labelled with the patient’s name, medicine name, strength of the
medicine, name and address of the supplier and date of dispensing
(which should be no greater than six months prior to the current date) or
the medicine expiry date (whichever is the shortest)
 For medicine dispensed in a brown bottle, the medicines must be of a
good visible quality and not mixed with other medications. Extra caution
should be exhibited when checking medicines not dispensed in ‘patient
packs’ (i.e. pre-packaged in foil containers which help in the identification
of the product)
 Care should be taken to note any specific storage requirements
2.2.7 Patients bringing medicines into the Trust in monitored dosage systems
(blister packs) may have medicines administered from the pack, provided that
each blister contains a single medication that is clearly labelled and that the
medication in the pack, as stated by the community pharmacy labels, match
the medicine prescribed.
2.2.8 Patients Own Medicines will be returned to the patient on discharge if they
are consistent with their discharge medicines.
2.2.9 All acute wards have a daily visit (Monday – Friday) from the ward pharmacist
who will clinically assess patients’ prescribed medicines. Ward pharmacy
technicians also work alongside Pharmacists as a team to organise supply for
newly prescribed items, discharges and liaise directly with the Pharmacy
Dispensary.
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2.3 Dispensing & Supply of Chemotherapy
2.3.1 All oral chemotherapy agents must be handled with care and dispensed in
original packs where possible. The dispensed item will be clearly labelled
“Cytotoxic Drug”. Cytotoxic drugs needing to be dispensed within a blister
pack must have an assessment completed by the appropriate healthcare
professional accompanying the request
2.3.2 All intravenous cytotoxic medicines will be dispensed in a ready-to-use form

by pharmacy aseptic services. Separate policies ensure safe preparation in
pharmacy facilities. A full risk assessment should be completed if cytotoxic
medicines are to be prepared in any area other than the Pharmacy aseptic
suite.
2.3.3 The person undertaking the manipulations to prepare the dose must be doing
so safely and within his or her own scope of competence and wearing
appropriate protective clothing. A cytotoxic spillage kit must be available.
2.3 Transport and receipt of medicines
2.4.1 Transport of Medicines in the Hospital
2.4.1.1 If a patient moves from one ward to another, any medicine supplied for their
use from pharmacy or any patient’s own medicine must be transferred with
them. In the case of controlled drugs, please refer to the Trust Policy on the
Safe and Secure handling of Controlled Drugs.
2.4.1.2 Where medicines need to be transported between wards and departments,

transfer should be carried out in such a manner that prevents loss or improper
use.
2.4.1.3 Medicines will normally be transported in security sealed transit bags or

boxes. Exceptions to this are supplies of bulk fluids. The container must be
either handed to a member of ward staff or left in a suitably safe ward area
where it must be brought to the attention of the nursing staff. Medicines
requiring refrigeration will be brought to the attention of the nursing staff for
immediate unpacking and placing in the refrigerator (in some cases this is
done through using separate labelled container).
2.4.1.4 Any member of staff collecting medicines from pharmacy must produce a
valid hospital identification badge. Failure to do so will result in pharmacy
refusing to supply the medicines.
2.4.1.5 When receiving stock items onto a ward the order should be checked against
the delivery note and the delivery note signed and dated by the person
reconciling the order. The delivery note must be returned to Pharmacy within
24 hours. Any discrepancies should be immediately notified to the pharmacy
department.
2.4.1.6 Controlled Drug orders must be signed by ward staff immediately on receipt
on the ward/clinical area.
2.4.1.7 All hospital discharge medicines must be received by a registered

nurse/midwife who must lock them in a medicine cupboard immediately, until
required.
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2.4.1.8 Consignment notes for Controlled Drugs, at risk medicines and medicines
requiring refrigeration (e.g. vaccines) must be completed by both staff
transporting and receiving medicines. Staff should print their name on the
consignment note, indicate the seal number, sign and date and return to
pharmacy within twenty four hours.
2.4.1.9 Whenever possible, medicines should not be carried by health professionals

outside Trust premises. However, in some circumstances certain designated
people may need to carry medicines, e.g. pharmacy staff, community
midwives, district nurses, community psychiatric nurses, community learning
disabilities nurses, health visitor’s etc. The responsibility for the security of the
medicines lies with the individual carrying the medicines. These designated
people must ensure that medicines are transported in a safe and secure
manner at all times. It is expected that each practitioner will use their
judgement to choose the safest method of transportation under the
circumstances.
2.4.2 Transport of Medicines by Community Services Staff
2.4.2.1 Community nurses are not normally advised to carry medicines that have
been prescribed / dispensed for named patients.
2.4.2.2 Patients/carers should collect prescriptions themselves. Where this is not

possible many local pharmacies operate a delivery service.
2.4.2.3 School Health Nurses, District Nurses and Health Visitors are permitted to
carry vaccines for domiciliary vaccination as per policy and administer them
as stated in the appropriate Patient Group Direction or prescription. School
Health Nurses may transport vaccines for school immunisation programmes.
In each case, vaccines must be stored in cool boxes (appendix two).
2.4.2.4 In exceptional circumstances Health Care Professionals may carry Controlled

Drugs or Prescription Only Medicines that have been prescribed for named
patients. The Health Care professional collecting such Controlled Drugs or
Prescription Only Medicines will be required to produce identification to the
pharmacist/dispensing GP in the form of either their Trust or Employers ID
badge. The medicines must be transported from the dispensing
Pharmacy/GP directly to the patient, out of sight in a locked car. Medicines
should not be left unattended in a car.
2.4.2.5 Health professionals may carry medicines necessary for them to fulfil their
professional duties in accordance with relevant directions or guidance from
their professional regulatory bodies, or as authorised by the Trust (e.g.
nursing staff who have undergone approved training for the management of
anaphylaxis, may carry adrenaline injection 1 in 1000 to respond to
anaphylactic reactions when undertaking vaccination clinics).
2.5 Supplying medicines for patients to use outside hospital
2.5.1 Medicines supplied for a patient to take away from the Trust must state:
 Patient’s name
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 Date issued
 Medicine name, strength and form
 Quantity supplied
 Name and Address of the supplier (The Trust)
 Directions for use
They can only be issued:
 From a pharmacy dispensed hospital discharge prescription (eDNF)

 From a pharmacy dispensed outpatient prescription
 As a pharmacy pre-labelled pack under a Patient Group Direction
 As a pharmacy pre-labelled pack against the prescription of a doctor
 Patient’s Own medicine returned to the patient at discharge
2.5.2 Medicines supplied for specific named patients to take out of hospital on
discharge or outpatient prescriptions must not be issued to another patient.
2.5.3 General unlabelled ward stocks must not be given to patients to take
home.
2.5.4 Supply of Hospital Discharge Medication:
2.5.4.1 All medicine required by the patient on discharge should be written on e-DNF.
This should be written when the patient is “amber” on the discharge traffic
light system to expedite the discharge process. This should be completed the
day prior to discharge.
2.5.4.2 The nurse should inform the ward pharmacist or pharmacy technician of any
patients due for hospital discharge. The pharmacist will clinically check the e-
DNF, the pharmacy technician may then check the patient’s medicine in the
POM box against the e-DNF on the ward. The patient should receive a
minimum of 7 days supply of their discharge medicines (14 for items newly
initiated or modified during their admission).
2.5.4.3 If there is insufficient supply in the POM box, existing home supplies of
regular medications will be confirmed. Where the patient requires an
additional supply of medicine this will be provided. If the supply is complete
on the ward by the Pharmacy ward based team, the e-DNF can be signed off
on the ward. Discharge medicine is supplied to the patient in the green
medicine bag and the patient counselled appropriately.
Discharges requiring the pharmacy dispensary to complete the supply can

only be completed if the drug chart and patients own medications are
returned to the dispensary. The e-DNF will then be signed off in the
Department by the staff on duty
2.5.4.4 In-patient supplies are dispensed in original packs labelled with directions so
that the medicine is available and ready on the ward when the patient is due
for hospital discharge.
2.5.4.5 If the ward pharmacist or pharmacy technician are unavailable the nurse must
bleep their designated ward pharmacy team for advice before sending all the
patients medicines in the POM box to pharmacy in a green medicines bag
along with the medicines chart in a sealed blue pharmacy bag
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2.5.4.6 All discharge medicines sent from pharmacy to the ward should be checked
against the prescription by a nurse before giving to the patient and
counselling provided appropriately.
2.5.4.7 Nurses on surgical wards may provide simple analgesia, laxatives and proton
pump inhibitors for a patient to take home when following the guidance in:
‘Protocol for the Supply of Medicine to Patients for Discharge by Nurses
within the Surgical Division’.
2.5.4.8 If required, the Trust has a number of link worker interpreters who may be
able to offer language/communication support. An interpreter should be used
if there are difficulties explaining medicine instructions to patients or their
carers where English is not a first language and where alternative forms of
communication support are required.
2.6 Supply of medicines to clinical areas when pharmacy is closed
2.6.1 Emergency Medicine Mediwell
2.6.1.1 Pharmacy provide access to Emergency Medicines out of hours via an

electronic Mediwell Cabinet and is located on the bottom corridor, opposite
A+E entrance.
2.6.1.2 Access is available only to Pharmacy staff or registered nurses with access
(this may also include bank staff). The outer door is swipe access and upon
entering the cupboard the alarm must be deactivated. Failure to deactivate
will result in the alarm going off. The Mediwell cabinet is accessed using a
combination of biometrics (fingerprint analysis) and hospital identification
badge swipe access. For full details of access and operation, please refer to
the Mediwell Cabinet Operational SOP.
2.6.2 Emergency Duty Pharmacist / Out of Hours Pharmacy Service (see appendix
four)
2.6.2.1 Pharmacists provide a 24 hour service for emergency and urgently needed
supplies and advice on medicines. They do not provide a dispensing service
for discharge prescriptions or outpatient prescriptions.
2.6.2.2 For access to medicines out of normal working hours, the Stock Location list
should have been consulted first. This list can be found on the Trust Internet
site. Select Trust Intranet site at the bottom of the Trust Internet home page.
Once on the Trust Intranet home page, select “Useful Links” > “Departments”
> “Pharmacy” > “Emergency Medicines”. If the medicine needed is not listed,
Contact the night sister/ on-site Manager who will confirm that the correct
procedure has been followed and then they must contact switchboard and
request the switchboard operator to ring the Pharmacy pager for that on-call
period and connect them while they wait.
2.6.2.3 The Emergency Duty Pharmacist may advise:
 borrowing the medicine from another clinical area (for further information
see section 3.6.3), or waiting until the pharmacy is next open
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 contacting the prescriber to amend the prescription to an item more
readily available
 that the patient’s own supply is brought in from home
2.6.3 Borrowing medicines
2.6.3.1 Medicines must not be borrowed from other clinical areas when pharmacy is
open.
2.6.3.2 It is unacceptable to borrow controlled drugs from another clinical area,

except in exceptional circumstances - (please refer to the Trust Policy on the
Safe and Secure handling of Controlled Drugs).
In accordance with robust stock management, it is the responsibility of the

registered nurse/midwife in charge of a clinical area to ensure that controlled
drug stocks are sufficient to cater for out of hours periods.
At risk drugs such benzodiazepines should not be borrowed between wards

without the authorisation of the on-call pharmacist
2.6.3.3 To transfer stock between clinical areas within the Trust when the pharmacy
is closed, the senior night sister / clinical co-ordinator on site cover must be
contacted to authorise the transfer.
2.6.3.4 Only boxes or bottles in their original packaging may be borrowed (except for
controlled drugs). Transfer of individual doses of medicines not in their
original containers increase the risks of medicine administration errors.
2.6.3.5 The borrowing clinical area must, once authorisation has been received from
the senior nurse on site cover:
 contact the ward holding the required medicine
 fill out the “stock transfer form” (appendix three)
 provide details of the request and of the member of staff being sent to
collect the item
 ensure the member of staff collecting the item has their hospital
identification badge and a copy of the chart where the medicine has been
prescribed
 sign the Stock Transfer Form upon receipt of the item
2.6.3.6 The clinical area issuing the item must check the following prior to release of
the item:
 ensure they have received an advanced request from the requesting ward
detailing the request, if not they should contact that ward to verify the
need for the item
 check the hospital identification badge of the member of staff collecting
the item
 check the stock transfer form against the prescribed item on the medicine
chart (ensuring the ward, patient details and dates match) and complete
the form
 issue the item
 send a copy of the transfer form to the Pharmacy and send the original to
the Nurse in Charge of that clinical area
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2.6.3.7 Pharmacy MUST be involved if medicines are required from anywhere
outside the Trust, including other acute trusts.
2.6.4 Obtaining patient discharge medicines out of hours
2.6.4.1 A patient’s discharge from hospital should be planned and discharge

prescriptions should be written in advance as per the Trust Discharge Policy.
2.6.4.2 It is the role of the Senior Sister or the nurse in charge of the ward to ensure
that discharge prescriptions are written in a timely manner so dispensing can
be achieved within pharmacy working hours.
2.6.4.3 It is not the role of the Emergency Duty Pharmacist to provide dispensing of
discharge prescriptions.
2.6.4.4 If the hospital is undergoing a Trust-wide bed crisis, the Site Manager will
consult with the Emergency Duty Pharmacist about the situation in the Trust
and together will plan how best to manage the discharge of patients.
2.6.4.5 In some circumstances it can be possible to discharge the patient using:

 pharmacy pre-labelled packs
 patient’s own medicines
 medicine provided for that individual patient as part of the “one stop”
service
In all of the above situations:
 a hospital prescription (TTO) must be written by a Trust approved

prescriber
 the medicine must be assembled, ensuring that where any pharmacy pre-
labelled packs are supplied that the following are completed:
o patient’s name
o date
o directions
 each item prescribed must be checked for the following:
o medicine name, form and strength matches the prescription
o contents of the container contain the correct medicine
o directions on the label match the prescription
o the patient’s name and the date are on the label
o the medicine is in date
o the quantity is appropriate
 a doctor or registered nurse must check the medicine against the
prescription and endorse the prescription “discharged from ward –
medicine checked by doctor” and sign their name, print their name and
date it
 a registered nurse should provide a second check of the medicine prior to
giving it to the patient, should sign and print their name and date the
prescription
 the patient is to have the medicine explained to them as per usual practice
 the pharmacy copy of the discharge prescription should be made
available for pharmacy to check the following day
2.3.4.6 Patient’s must not be discharged with medicines placed in envelopes.
15
2.6.4.7 Patients being provided with medication from the A&E Departments may be
treated under Patient Group Directions. In this case, two nurses may check
the medicine provided.
2.7 Specific considerations for paediatrics
2.7.1 Take Home Medicines
2.7.1.1 The majority of children will be discharged on a planned basis in the normal
manner. However it is recognised that there may be a few exceptional cases
when this will not occur.
2.7.1.2 There will be a limited supply of commonly used paediatric medicines

dispensed and labelled ready for issue on a prescription from medical staff
and held on the unit. The label must include the child’s name and date of
supply. If instructions need to be added to the label the doctor should do this.
The nurse must check the label before the bottle is issued and this should be
documented on the prescription sheet. Once the prescription has been
dispensed and given to the parents a copy must be placed in the appropriate
file in the ward to be collected by a pharmacy technician to enable the stock
to be replenished on the Unit.
2.7.2 Hospital at Home
2.7.2.1 Qualified children’s nurses staff the service and lead the care of the child,
whilst a name paediatrician assumes overall responsibility.
2.7.2.2 Medicines are obtained from the Trust’s pharmacy and it is the nurse’s
responsibility to ensure safe guards for storage and transport to and from the
child’s home.
2.7.2.3 Take home medicines for IV antibiotics will have the dosage on the label,
taking into account the displacement volume, along with a brand specific
sheet that accompanies the IV antibiotics clearly recording the appropriate
displacement value calculation
2.7.2.4 The registered nurse may administer IV drugs in the absence of a second
nurse. They will ask a relative to ‘confirm’ the drug whenever possible.
2.8 Dispensing/ Supply Medicine Errors
2.8.1 Any medicine dispensed or supplied incorrectly must be reported using the
Trust Incident Reporting process. Any incidents relating to fraud must be
reported on Datix and also reported to the Chief Pharmacist. These will be
forwarded onto the LCFS accordingly.
16
3. STORAGE & SECURITY OF MEDICINES
3.1 Introduction
3.1.1 The responsibility for organising, monitoring and reporting on a system for the
safe storage and handling of medicine lies with the Chief Pharmacist of the
Trust, in consultation with medical and nursing staff.
3.1.2 Pharmacy staff have a responsibility to advise practitioners on the safe and
secure storage of medicines in clinical areas, the maintenance of an audit trail
in relation to stocks of medicines and to ensure that medicines supplied are of
a suitable quality and are stored in appropriate legal and environmental
conditions.
3.1.3 Senior Sisters / lead professionals are responsible for ensuring that the
security of medicines within their ward areas is maintained at all times.
3.1.4 In departments / clinics where there may be no registered nurse or midwife,

the professional head of service is responsible to ensure compliance with this
section of the policy.
3.2 Storage & Security of medicines within clinical areas
3.2.1 Each ward or clinical area will have a range of medicines which are kept as
stock items. The Pharmacy Department or ward based Pharmacy team and
the manager of the ward or clinical area will modify this list according to the
speciality or requirements of that ward, and review this list every three
months. Items required that are not stock, will be supplied as individual
named patient supplies.
3.2.2 The Pharmacy Service will monitor the prescription and usage of medicines
on a regular basis. Concerns will be reported to the Lead Pharmacist for the
business unit and the manager of the clinical area. These should be
escalated to the Chief Pharmacist where appropriate. Incidents concerning
the storage and security of medicines must be reported using the trust
incident reporting system. The manager of the clinical area and the Lead
Pharmacist for the business unit are responsible for ensuring the incident is
investigated, a record made of the process and recommended action.
3.2.3 All staff have a responsibility to ensure medicines are stored securely,
however the manager of each clinical area will be accountable for the safety
and security of all medicines issued to the clinical area.
3.2.4 The security of controlled drugs must be managed in accordance with the
Trust Policy on Safe Management of Controlled Drugs.
3.2.5 Medicines must be stored in the containers in which they are supplied by the
Pharmacy department. They must not be transferred to another container.
17
3.2.6 Medicines must be locked away when not attended. This includes medicine
trolleys, refrigerators, cupboards, patients own medicine (POM) lockers and
Mediwell cabinets. Where access to clinic rooms is via a PIN code then this
PIN code should be changed every 6 months.
3.2.7 Different formulations of medicines need to be stored appropriately for their

use.
Products should be stored separately according to the following categories:
Products For External Use All products intended for external use must be stored separately
from other medicines. This is a lockable cupboard for the storage
of lotions and other external medicines and for the storage of
substances that are not intended for medicinal use, and that could
be harmful; e.g. disinfectants, HAZ tabs, concentrated antiseptics,
urine testing equipment. This cupboard can also be used to store
topical preparations, enemas and suppositories. This cupboard
should be locked when not in use.
Products for Internal Use All products intended for internal use should be stored separately
from other medicines.
Products for Parenteral These should be stored separately from medicines for internal
Use use.
Controlled Drugs All CDs must be kept in the separate Controlled Drug (CD)
cupboard (refer to Trust Policy on Safe Management of Controlled
Drugs). The CD cupboard must be used only for the storage of
CDs and other specified drugs (e.g. Concentrated Potassium
Chloride Injection)
The cupboard must comply with the design specification
standards as required by the ‘Controlled Drugs Safe Custody
Regulations 1973’.
Medicine Trolley Where a medicine trolley is in use, it must be supervised at all
times by a registered nurse administering medicines during
medication rounds The trolley must be secured to an internal wall
when not in use. This key must be different to all other cupboard
keys and should be kept on the person in charge of the clinical
area or a registered nurse or member of pharmacy staff.
Medicines/vaccines A lockable fridge is mandatory for the storage of internal and
Refrigerator external medicines that need to be stored between 2 - 8oC.
It is the responsibility of the Ward Manager/responsible

professional, to ensure the fridges in all clinical areas are in good
working order, have uninterrupted electrical supply, be clean, and
have min./ max temperature monitoring facilities.
The temperature of the refrigerator must be maintained at 2 – 8oC

and should be monitored with a maximum / minimum
thermometer on a daily basis. A log of maximum/minimum
temperatures should be recorded daily, on days when the
ward/clinic is in use. It is the responsibility of the professional in
charge to ensure this is done.
Where temperatures are found to have deviated outside of this

range, advice should be sought from pharmacy on how to
18
manage the medicines stored inside the refrigerator.
There will be at least an annual calibration of the fridge

thermometer and service of the medicine/vaccine fridge.
It is good practice that a log is kept of the time at which items are
removed from the refrigerator, to ensure that items returned to the
refrigerator have not been out for longer than the manufacturers
specified time.
When not refrigerated, vaccine must be stored in a cool box with

a pre-frozen ice pack. Individual vaccines should not be returned
to the fridge on more than one occasion.
See Procedure for the safe storage of vaccines, for more detail on
vaccine storage.
The medicines fridge must not be used to store anything other

than medicines (i.e. food or drink must not be stored in the
medicines fridge) and should be locked when not in use.
Patients Own Medicines Where One Stop Dispensing service is in operation, all medicines
Boxes should be stored in a Patients Own Medicine (POM) Box which
should be attached to either the wall near to the patient or the
bedside locker.
The person in charge of the clinical area, a registered nurse or a
member of pharmacy staff should keep the keys to these boxes.
Patients may also keep a key if they have been assessed as
suitable for “self-medication” in accordance with East Cheshire
NHS Trust Policy.
Intravenous Fluids and Intravenous fluids and irrigation fluids should be stored in such a
Irrigation Fluids way as to avoid selection errors.
Fluid bags should not be mixed. They should remain in the

original box.
Fluid boxes should be stored neatly, so as not to cause an

obstruction in the clinical area
Emergency Resuscitation Emergency medicines are stored in red (adult) or blue (paediatric)
Medicines boxes on the emergency trolleys. Neonatal Resuscitation drugs
are stored in grey boxes in the hospital setting.
In the community setting, medicines for emergency use, should

not be locked away during clinic sessions, but should be stored
with the appropriate accessibility. They should be stored in a
tamper evident container and labelled for emergency use. They
should be stored securely when the clinic is not running. These
should be stored in a way that does not affect the integrity of the
product.
When an emergency pack is opened, it must be replaced.

Medical gases The number of cylinders held as stock in any department should
be as small as possible
The cylinders should be stored in a clean, secure area, under
19
cover (preferably inside) and not subjected to extremes of heat.
Safety chains, or a stand should be used to ensure that non-

portable cylinders are physically safe and prevent them from
falling over.
Naked flames, or lights and heat sources must be avoided. This

includes adjacent areas inside and outside the building. If
necessary, warning signs should be affixed on external walls of
the building. Naked flames or heat sources, including smoking,
should be avoided near the area where the gases are stored. It
should be remembered, smoking is not permitted on Trust
grounds.
No oil or grease, should be applied to the cylinder or tap

connector.
Allow for segregation of full and empty cylinders and permit

separation of different gases within the store.
Cylinders with damaged valves and defective equipment must be

labelled appropriately and withdrawn from use.
It is advisable to notify the emergency services of the location and

contents of the medical gas cylinder store.
Flammable Liquids COSHH data sheets should be available for all staff for any
flammable liquid kept on the premises.
Store in a locked cupboard that displays appropriate hazard sign.
Keep stock levels to a minimum to reduce the risk of combustion

or explosion.
Avoid spillage – keep bottle closed securely and replace cap

immediately after use.
Keep well away from naked flame, electrical apparatus or source

of heat.
Do not store in a refrigerator.
3.2.8 All cytotoxic medicines/chemotherapy must be stored in an appropriate

secure environment as advised by the Pharmacy department. A dedicated
locked refrigerator is available in the Macmillan Cancer Resource Centre for
the storage of intravenous chemotherapy.
3.2.9 Where premises are shared by a number of clinical services, each clinical
service is responsible for its own stock of medicines, which will be stored
separately.
3.2.10 In the community setting, all medicines cupboards must comply with the
current British standards. Approved NHS hardware suppliers will provide
medicine storage containers that met, or exceed, current regulations. (The
current standard is BS2881 (1989) – NHS Estates Building Note No 29).
20
3.2.11 In a patient’s own home, staff should encourage patients to store all
medicines (including medical gases) in a safe place, out of the sight and
reach of children and according to the manufacturers instructions, that
ensures the integrity of the product.
3.2.12 Statutory warning notices should be displayed where potentially hazardous

products are stored.
3.3 Patients Own Medicines
3.3.1 It is the policy of East Cheshire NHS Trust that on admission to hospital
patients are asked to bring their own medication with them. On admission, the
nurse should gain the patient’s consent and place all the patient’s own drugs
in the patient’s POM box on the wall/locker after first checking that the POM
box is empty. If the patient does not already have one, a green medication
bag should be placed in the POM box.
3.3.2 If the patient does not consent to having his / her medicines put into a POM
box the patient should be asked to have the medicines taken home. A new
supply of medicines will be provided by the hospital pharmacy which should
be locked in the POM box.
3.3.3 Medicines brought in by patients should only be used within the Trust when
they can be positively identified. Medicines will be assessed as per the Trust
Procedure for the Assessment of Patient’s own Medicines for use in the
Hospital by Pharmacy staff at the earliest opportunity.
3.3.4 Any patient’s own controlled drugs, including those of patients who are self
medicating, should be stored in the ward CD cupboard and a record of this
made in the controlled drug register (see Trust Policy on Safe Management of
Controlled Drugs).
3.3.5 A master key to all POM boxes will be held on the nurse’s key bunch. The
patient will not have access to the box without a nurse/pharmacist being
present, unless as part of a self-administration scheme. The Pharmacist will
also hold a master key.
3.3.6 Medicines supplied from pharmacy for a particular patient must be stored in
the patient’s POM box. Exceptions apply to reliever inhalers, eye drops for dry
eyes and glyceryl trinitrate sprays that are required as necessary for
treatment of chest pain. These may be stored on the patient’s bedside locker.
3.3.7 When the patient is transferred to another ward the patient’s medicine must
be removed and transferred with the patient to the other ward.
3.4 Mediwell Cabinets
For wards and clinical areas using Mediwell cabinets, please refer to Mediwell
Standard Operating Procedure and policy.
21
3.5 Keys
3.5.1 The safekeeping of the keys for medicine storage areas is the responsibility
of the nurse in charge of the ward, the most senior midwife or clinical
professional on the ward, theatre, department or clinic.
3.5.2 All acute wards should have no more than 2 sets of medicine cupboard keys
and a set of Controlled Drug cupboard keys. POM box keys can be attached
to each bunch of keys on the ward. These should be able to be used to open
the boxes without detaching the key bunch from the uniform.
3.5.3 The controlled drug cupboard keys should be held by the nurse in charge and
attached to the uniform on a red ‘curly whirly’. The keys may be handed over
to other trained staff but should be returned after use. It is the responsibility of
the nurse in charge to hand over the keys at the end of the shift to the
incoming nurse in charge.
3.5.4 In Community services, the keys should be kept on one key ring, solely for
storage of medicine cupboard keys, and be in possession of the responsible
professional who controls access to medicines. When not in use, the keys
should be stored in a locked key cupboard.
3.5.5 Keys may be temporarily handed to medical and pharmacy staff, as

necessary, for fulfilment of their duties. On such occasions, that particular
clinical professional is responsible and accountable for ensuring that all
relevant medicines policies and procedures are correctly adhered to,
including the safe return of any keys to the registered nurse or midwife in
charge. However, the most senior registered nurse/midwife retains the overall
responsibility for medicines security for that area.
3.5.6 An auxiliary nurse can have possession of the keys to clear POM boxes or
access external medication cupboard but they must NOT have the CD
cupboard keys. The keys must be returned to the appropriate trained nurse
as soon as they have been used.
3.5.7 Keys must not be left in the locks of POM boxes, fridges, medicine cupboard
or trolleys when not in use, and should be kept on the person of a registered
nurse at all times.
3.5.8 Any loss of keys should be reported immediately to the appropriate clinical
manager or senior nurse on duty and Pharmacy (the on-call pharmacist if out
of hours). Investigation of the loss of keys must be an immediate priority.
Every effort needs to be made to recover the keys. An incident form must be
completed. If the keys have left the hospital, the incident must be escalated to
the Associate Director of the directorate or site manager if the keys cannot be
retrieved. The risks of this will need to be assessed and the need to change
locks considered. For clinics in community services which have drug
cupboards, there must be an agreed lost key procedure, and all staff must be
made aware of this.
3.5.9 Duplicate/ spare keys are placed in the emergency key cupboard. When
accessing these keys the senior nurse must complete an incident form and
make a record of where the keys are to be used.
22
For community services, who are based outwith the Macclesfield District
General Site, a suitable, locked, secure storage site, should be identified for
spare sets of keys. There should be a local protocol, to ensure all key
members of staff, know how to access the spare keys.
3.5.10 Wards must not keep spare sets of keys in the ward safe.
3.5.11 When a ward, department or theatre is temporarily not involved in the active
treatment of a patient or is closed e.g. overnight or weekend, the drug
cupboard keys must be returned to a place of safe keeping and be managed
in such a way as to prevent unauthorised access.
The advice of the Pharmacy Department must be sought if the duration of

closure is longer than overnight or a weekend.
3.6 Controlled Drugs & Illegal or suspicious substances
3.6.1 For guidance on the storage and security of CD’s and dealing with illegal or
suspicious substances, please refer to the Trust Policy on Safe Management
of Controlled Drugs.
3.7 Missing medicines
3.7.1 Missing medicines must be immediately reported to the lead senior nurse for
the area and the pharmacy. Out-of-hours, they should be reported to the
appropriate clinical manager and senior nurse on duty and the lead senior
nurse and pharmacy should be informed as soon as possible.
3.7.2 The person making the report must complete a Trust Incident Report Form
and provide a signed, written statement.
3.8 Controlled Stationery
3.8.1 Controlled stationery is any stationery that could be used to obtain medicines
fraudulently (Duthie Report, 1988 updated 2005).
3.8.2 Within the hospital setting controlled stationery refers to the controlled drugs
order book used to requisition controlled drugs for clinical areas. This book is
kept in a locked drawer or cupboard in each clinical area.
3.8.3 Within outpatient clinics, this refers to FP10 (HP) prescription pads (where in
use), which are used to prescribe medicines by approved practitioners.
3.8.4 Controlled stationery, within the hospital is currently held and supplied by:
 Pharmacy Department (controlled drug order books, FP10 (HP)s)
3.8.5 Controlled stationery remains under the control of the departments listed
above. A designated person within each of those departments is responsible
for the receipt and issue of controlled stationery. A member of pharmacy
should check records periodically and any anomalies investigated.
3.8.6 Stock/record sheets will be kept for the receipt and issue of all controlled
stationery, including the following information:
23
 Date of receipt/issue
 Person requisitioning stationery
 Quantity and type of stationery supplied
 Stationery numbers where appropriate
3.8.7 All controlled stationery should be uniquely numbered.
3.8.8 Loss or theft of controlled stationery must be reported to the person in charge
of the clinical area and also the Chief Pharmacist. An incident form must also
be completed.
3.8.9 Records should be kept of controlled stationery returned to the supplying

departments and of controlled stationery that is destroyed.
3.8.10 Controlled stationery, once issued to a clinical area, must be kept in a secure
place; this includes community clinical areas. FP10HP pads must not be left
unattended on desks or worktops in the clinic. The security of the stationery is
the responsibility of the person in charge of the clinical area.
3.8.11 All staff have a responsibility to ensure that official/medical stationery is kept
safe and secure, to prevent its misuse.
3.8.12 Under no circumstances should blank prescription forms be pre-signed before

use.
3.8.13 With respect to the Community Services
Stocks of prescription pads, prescription forms for computer printing and

requisition forms should be ordered using the approved system for the service
concerned and kept in a secure area. It is good practice to keep a separate
record of prescription serial numbers in the event of theft / loss. They should
contact the police, to report lost or stolen prescriptions.
Loss, or theft of blank prescriptions should be reported to Contractor Services

Department at Cheshire Health Agency (Tel: 01244 650449 Mon-Fri 9am-
5pm) immediately. Serial numbers of lost/stolen prescriptions must be
provided). They will alert all Pharmacies and the Prescription Pricing Division.
The prescriber, is to inform their line manager on that day. The prescriber,
should write prescriptions in red ink for the next month.
24
Appendix one
Equality Analysis (Impact assessment)

1. What is being assessed?
The Trust policy for the Dispensing and Storage of Medicines
Details of person responsible for completing the assessment:

 Name: Kashif Haque
 Position: Chief Pharmacist
 Team/service: Pharmacy
State main purpose or aim of the policy, procedure, proposal, strategy or

service:
This policy provides guidance relating to the dispensing and storage of medicines for all staff in East
Cheshire NHS Trust (ECT).
2. Consideration of Data and Research

To carry out the equality analysis you will need to consider information about
the people who use the service and the staff that provide it.
2.1 Give details of RELEVANT information available that gives you an

understanding of who will be affected by this document
Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire
West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011,
370,100 people resided in CE and 329,608 people resided in CWAC.
Age: East Cheshire and South Cheshire CCG’s serve a predominantly older population
than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged
over 85 (9,700 people).
Vale Royal CCGs registered population in general has a younger age profile compared
to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85
(2,111 people).
Since the 2001 census the number of over 65s has increased by 26% compared with
20% nationally. The number of over 85s has increased by 35% compared with 24%
nationally.
Race:
 In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White
British
 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK –
Poland and India being the most common
25
 3% of CE households have members for whom English is not the main language
(11,103 people) and 1.2% of CWAC households have no people for whom
English is their main language.
 Gypsies & travellers – estimated 18,600 in England in 2011.
Gender: In 2011, c. 49% of the population in both CE and CWAC were male and
51% female. For CE, the assumption from national figures is that 20 per 100,000 are
likely to be transgender and for CWAC 1,500 transgender people will be living in the
CWAC area.
Disability:
 In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health
problem or disability
 In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+
with dementia in CWAC. 1 in 20 people over 65 has a form of dementia
 Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment
or deafness.
 C. 2 million people in the UK have visual impairment, of these around 365,000
are registered as blind or partially sighted.
 In CE, it is estimated that around 7000 people have learning disabilities and 6500
people in CWAC.
 Mental health – 1 in 4 will have mental health problems at some time in their
lives.
Sexual Orientation:
 CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in
CE was estimated at18,700, based on assumptions that 5-7% of the
population are likely to be lesbian, gay or bisexual and 20 per 100,000 are
likely to be transgender (The Lesbian & Gay Foundation).
 CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010
there were c. 20,000 LGB people in the area and as many as 1,500
transgender people residing in CWAC.
Religion/Belief:
The proportion of CE people classing themselves as Christian has fallen from 80.3%
in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the
proportion saying they had no religion doubled in both areas from around 11%-22%.
 Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester
 Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester
 Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester
 Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester
 Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester
 Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester
 Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester
 None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester
 Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester
26
Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and
just over 11% (37,000) of the population in CWAC.
2.2 Evidence of complaints on grounds of discrimination: (Are there any

complaints or concerns raised either from patients or staff (grievance) relating
to the policy, procedure, proposal, strategy or service or its effects on
different groups?)
No- none aware of
2.3 Does the information gathered from 2.1 – 2.3 indicate any negative
impact as a result of this document?
No
3. Assessment of Impact
Now that you have looked at the purpose, etc. of the policy, procedure,
proposal, strategy or service (part 1) and looked at the data and research
you have (part 2), this section asks you to assess the impact of the policy,
procedure, proposal, strategy or service on each of the strands listed
below.
RACE:
From the evidence available does the policy, procedure, proposal, strategy
or service affect, or have the potential to affect, racial groups differently?
No
Explain your response: Applies equally to all staff employed by the

organisation. Translation services are available for patients who do not speak
English
GENDER (INCLUDING TRANSGENDER):

or service affect, or have the potential to affect, different gender groups
differently? No
organisation. The Trust has a transgender policy and staff will be mindful of
this.
DISABILITY:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, disabled people differently? No

organisation.
AGE:
or service, affect, or have the potential to affect, age groups differently? No
27
organisation.
LESBIAN, GAY, BISEXUAL:
or service affect, or have the potential to affect, lesbian, gay or bisexual
groups differently? No
organisation.
RELIGION/BELIEF:
or service affect, or have the potential to affect, religious belief groups
differently? No
organisation.
CARERS:
or service affect, or have the potential to affect, carers differently? No

organisation. Carers will be involved in any explanations of medication prior to
discharge where this will support the patient and aid compliance.
OTHER: EG Pregnant women, people in civil partnerships, human rights issues.

or service affect, or have the potential to affect any other groups differently?
No

organisation.
4. Safeguarding Assessment - CHILDREN

a. Is there a direct or indirect impact upon children? No
b. If yes please describe the nature and level of the impact (consideration to be
given to all children; children in a specific group or area, or individual children.
As well as consideration of impact now or in the future; competing / conflicting
impact between different groups of children and young people:
c. If no please describe why there is considered to be no impact / significant
impact on children.
This policy only relates to staff in relation to the dispensing and storage of medicines
5. Relevant consultation
Having identified key groups, how have you consulted with them to find out their views
and that the made sure that the policy, procedure, proposal, strategy or
service will affect them in the way that you intend? Have you spoken to staff
groups, charities, national organisations etc?
Medicines Management Group
28
6. Date completed: 28/12/16 Review Date: January 2019
7. Any actions identified: Have you identified any work which you will
need to do in the future to ensure that the document has no adverse impact?
Action Lead Date to be Achieved
8. Approval – At this point, you should forward the template to the

Trust Equality and Diversity Lead lynbailey@nhs.net
Approved by Trust Equality and Diversity Lead:
Date: 28.12.16
29
Appendix two
Procedure for the Safe Storage of Vaccines (Community Services Business Unit)
All vaccines must be stored in accordance with manufacturers’ recommended
temperatures in order to ensure that their potency is maintained. The Department of
Health has issued minimum national standards for vaccine storage.
Procedure Rationale
1.
A suitably trained person should be nominated The procedure will be
for each clinic area to be responsible for the adhered to and records
safe storage of vaccines. kept up to date.
A second trained person should be nominated

to deputise during times of absence.
2. Maintenance of correct storage
temperatures
2.1 Manufacturers’ recommendations on storage The potency of vaccines
must be adhered to. Vaccines must be stored can only be guaranteed
between 2 to 8 oC in the refrigerator on receipt if manufacturer’s
of delivery. recommended storage
conditions are
maintained.
2.2 A maximum / minimum thermometer should be Temperature dials are
used in refrigerators, where vaccines are unreliable as they need
stored. Temperature indicator dials must be to be calibrated by use
disregarded. of a thermometer.
2.3 Maximum and minimum temperatures reached Extremes of temperature
within the refrigerator should be recorded each will be noted.
working day.
2.4 In the event of temperatures going outside the The Medicines
recommended range, contact the Medicines Information Service will
Information Centre at MCHT or ECHT. advise whether the
vaccines are fit for use.
2.5 Vaccines must never be kept below 0 oC. Any Freezing causes
vaccines exposed to these temperatures must significant deterioration
be discarded. of the vaccine and may
breakdown the
container.
2.6 Vaccines must be stored in the main body of To ensure vaccines are
the refrigerator, allowing air to circulate around maintained at
the packages. They must not be stored on the recommended
shelves or storage compartments of the temperatures.
refrigerator door.
2.7 Domestic refrigerators are not designed for Medicine fridges ensure
storage of vaccines and should not be used. the reliable maintenance
of temperature
3 Maintenance of vaccine refrigerators
3.1 Vaccines must be transferred to an alternative Vaccines will be
30
drug refrigerator or stored in an insulated cool maintained as far as
box during defrosting of vaccine fridges. possible at the correct
temperature.
3.2 Fixed spur wiring should be fitted for vaccine Refrigerators will not be
fridges. If this is not practical, refrigerator unplugged accidentally.
plugs and sockets should be covered with tape
which reads ”DRUG REFRIGERATOR - DO
NOT SWITCH OFF”
3.3 Refrigerators used for vaccine storage should Vaccines are medicines:
be lockable and used exclusively for therefore, access should
medicines. be limited to authorised
staff.
4. Shelf life of reconstituted multidose

vaccines
4.1 Reconstituted vaccine must be used within the If reconstituted beyond
recommended period varying from one to four recommended period,
hours, according to manufacturers’ instruction. the stability of the
vaccine cannot be
guaranteed.
4.2 Once opened, multidose vials must be Unacceptable levels of
discarded at the end of the vaccination contamination will be
session. avoided.
5 Disposal of unused vaccine
5.1 Expired and partly used vaccines must be Incineration is the
disposed of in a bin for incineration, together recommended method of
with used ampoules and vials. disposal for all drugs,
also many vaccines are
live.
6. Batch number and expiry date
6.1 The batch number of the vaccines and the The vaccine may be
manufacturer used must be recorded on traced in the event of an
whatever system is in place. adverse reaction.
6.2 The expiry date of the vaccine should be noted The safety and potency
prior to administration. Expired vaccines must of expired vaccines
be disposed of. cannot be guaranteed.
6.3 Care should be taken to avoid over ordering or Vaccines are not wasted
stock piling vaccines. Systems should be unnecessarily. Expired
developed to ensure stock rotation, and regular vaccines are not used.
checks should be made to remove time expired
vaccines.
7 Vaccines removed from the refrigerator for
use
7.1 Vaccines should be removed from the Re-warming and re-
refrigerator immediately prior to immunisation cooling of vaccines may
sessions. Only one box should be removed at make them unsafe.
a time. Partly used vaccines should be
disposed of in the Sharps Bin.
31
7.2 Vaccines must be transported in insulated cool Re-warming and re-
boxes for home/school immunisation sessions cooling of vaccines may
which contains a maximum/minimum make them unsafe
thermometer (ie kept between +2oC to +8oC).
Only remove sufficient quantity for the session
from the coolbox. Any unused vaccines can
then be returned to the fridge for future use.
NB: See procedure for the use of Insulated
Cool Boxes.
7.3 Any vaccine taken out of the fridge should be Re-warming and re-
marked to indicate it has been removed from cooling of vaccines may
the fridge before it is returned. make them unsafe
7.4 Once a vaccine has been marked as being Re-warming and re-
removed from the fridge, it should be used cooling of vaccines may
prior to other vaccines. A vaccine should only make them unsafe
be removed and returned to the fridge on one
occasion.
8. Vaccine spillage
8.1 Wear gloves, mop up excess and discard Some vaccines are live
soiled swabs in a bin for incineration. Clean and may be a potential
surface with Titan Sanitizer powder. Splashes source of infection.
on the skin should be washed with soap and
water. Eyes should be washed with copious All vaccines are
amounts of 0.9% saline and medical advice chemicals which need to
sought. be cleared up
appropriately.
32
Appendix three
RECORD OF MEDICINES TRANSFERRED BETWEEN WARDS WHEN

PHARMACY IS CLOSED
When pharmacy is closed, in the first instance medicines can be obtained via the
emergency drug systems operating in the hospital. If the required medicine is
not available through these systems then in exceptional circumstances in order to
avoid an unacceptable delay in administration, medicines can be obtained from
another ward using the ‘Transfer of Medicines between wards when pharmacy is
closed’ procedure.
This form must be used to record the transfer of medicines using that
procedure
Date & Time: ……………………………………………………………………………
Requesting ward / department ……………………………………………………….
Site: …………………………………………………………………………………….
Medicine required (including form, strength and dose) ………………………………….
Patient details (insert addressograph sticker)
Requested by…………………………… (sig) …..……………………………..(name)
Quantity of drug supplied ……………………………………………………………..
Supplied by … ………… ………….. (sig) ……………………(name)Ward/Dept
Transported by ………………………… (sig…………………………………..(name)
Received by …………………………….(sig)………………………………….(name)
A copy must be placed in an internal envelope immediately after

transfer is made and sent to pharmacy.
33
Appendix four
1 Scope:
This SOP applies to all East Cheshire NHS Trust staff based at Macclesfield District General
Hospital or Congleton War Memorial Hospital requiring urgently needed medicines or
medicines information for the treatment of patients at East Cheshire NHS Trust when
pharmacy is closed.
2 Overview:
The Pharmacy on call service is available to the Trust from Mon to Thurs 5pm to 8.45am,
Friday 5pm to 10am and weekends/ bank holidays from 1pm to 10.00am (excluding
Christmas Day where on-call service operates all day). The Pharmacy Department will be
open between 8.45am and 5pm on weekdays and between 10am and 1pm at weekends
and Bank Holidays.
Occasionally calls may be received from the Community. The on call service is not
intended to cover Community based advice or supply. Exceptions are the supply of
Palliative care drugs out of hours in exceptional circumstances. Requests for supply for
non-hospital patients should be referred to the GP on call service and Chemists out of
hours service for supply.
Pharmacist remuneration for on call is provided as per Trust Policy for on-call
remuneration, which is aligned with the Agenda For Change Terms and Conditions of
employment.
3 Supply of medicines for in-patients
3.1 The Nurse must carry out the following procedure and check all the areas listed
below before contacting the on-call Pharmacist:
3.1.1. Patient’s own medication (POM) box (if the patient has recently moved beds,
check the POM box of the bed they have been moved from)
3.1.2. The clinic room, for any medicine that has been delivered from pharmacy.
3.1.3. If transferred in, the previous ward/ Emergency Dept.
3.1.4. Check if the patient has bought their own supply in, or check if a relative can bring
their own supply in.
3.1.5. Availability of that medicine within the hospital by accessing the Trust Intranet site
(Infonet)
 Select “Hot Topics” from the left hand side of the screen
 Select “Emergency Drugs”. This displays an alphabetical list of all the medicines
stored in the Hospital. The location of the medicines within the hospital is listed
with each one
 Always use emergency supplies from the Emergency Drug Cupboard (Mediwell
365) first. If this location is out of stock, retrieve from an alternative location (ward/
clinical area)
 If a supply is borrowed from a ward/ clinical area, fill in a stock transfer note and
send a copy to Pharmacy
 If the medicine is still unavailable, a clinical decision must be made as to whether
there is an urgent/ emergency need for this medicine before Pharmacy is open
again. This may involve consultation with a Senior colleague or the Prescriber/ Dr.
on-call. The discussion with the medical staff must include an assessment if there
is an appropriate alternate drug that could be used and a check made if it is
available.
34
3.2 Contacting the on-call Pharmacist for an urgently needed medicine
3.2.1. Contact the night sister/ on-site Manager who will confirm that the correct
procedure has been followed and then they must contact switchboard and request
the switchboard operator to ring the Pharmacy pager for that on-call period and
connect them while they wait.
3.2.2. It is important the enquirer goes through switchboard as there are three
Pharmacy pagers. Switchboard will have a record of which one is being used. The
On Call Pharmacy List and telephone numbers are located in Book 3 to the left of
Console 1993. The Pager number in operation for the day is on the list marked
“today’s on call list”.
3.2.3. The Switchboard operator will not give the enquirer the number to contact the on-
call Pharmacist directly.
3.2.4. Switchboard will advise the caller to leave clear instructions as to caller name,
location and telephone number and advise the enquirer the response could be up to
20 minutes, as the on-call Pharmacist may be driving therefore unable to answer
unless they have a hands-free system to make phone calls.
3.2.5. If no response after 20 minutes, the enquirer should contact Switchboard again,
and repeat the pager message.
3.2.6. If no response after a further 10 minutes the enquirer must contact Switchboard
again and request escalation as per SOP, as the Pharmacist has not responded.
3.2.7. The enquirer will be put in park until the on-call Pharmacist can be reached using
one of the listed telephone numbers for them.
3.2.8. When the on-call Pharmacist has been successfully contacted, switchboard will
connect the enquirer to the on-call Pharmacist.
3.2.9. In exceptional circumstances when the enquiry is an emergency (e.g. major
incident), the enquirer should request escalation immediately and not wait for a
pager reply.
3.2.10. If the listed on-call Pharmacist remains unavailable or if both listed phone
numbers connect to an answer phone, the Switchboard operator will leave a brief
message identifying themselves and request that the on-call Pharmacist contacts
Switchboard urgently, then escalate to the Pharmacy Senior Management listed
below, immediately after leaving the message:-
Name Job Title

Lis Street Deputy Chief Pharmacist
Kashif Haque Chief Pharmacist
4 Emergency Supply of Controlled drugs/ At Risk Medicine

4.1 Requisitions for Controlled Drugs as stated in the Trust Safe & Secure Handling of
Controlled Drugs Policy, must be made from Monday to Friday during normal working
hours.
4.2 If required out of hours then one dose can be borrowed from another ward/ clinical area,
without having to contact the on-call Pharmacist. For further subsequent doses needed
for the same patient, the night sister/ on-site co-ordinator must contact the on-call
Pharmacist for approval before the dose is borrowed.
4.3 It is not necessary to contact the on-call Pharmacist to borrow one dose of a listed “At
Risk” medicine
5 Discharge medicines
5.1 All discharges should be processed during normal pharmacy working hours. Only in
35
exceptional circumstances will the on-call Pharmacist dispense a discharge prescription,
and the decision will be made taking into account the individual patient's circumstances.
5.2 If required, Senior Nurses and Doctors are able to process discharge prescriptions/
eDNFs out of hours without Pharmacy input:-
5.2.1. The Doctor must complete the discharge prescription/ eDNF in the usual way.
5.2.2. The Nurse must check the medicine chart against the discharge prescription/
eDNF to ensure that all items have been prescribed correctly.
5.2.3. The Nurse must obtain all medicines from the POM box and check each item and
the label is correct against the prescribed medicine. This must be checked by a
second nurse.
5.2.4. If a medicine is not in the POM box, the nurse should check what medicines the
patient has at home and if necessary, issue a patient-labelled pack (PLP) which
may be available in the Hospital. The emergency drug list on the infonet will have
details of where these are located.
5.2.5. If all the drugs are available but there is less than 14 days supply this must be
discussed with the patient/carer as to how further supplies will be obtained e.g. GP
or returning to collect further supplies.
5.2.6. If a correctly labelled supply of medicine is not available, or if a PLP is not
available, or if the patient does not have any at home, a supply will be issued to the
patient by Pharmacy the next day during normal working hours. The Prescriber and
patient/ carer must be informed.
5.2.7. When the medicines are assembled the nurse should open the medication tab on
the eDNF and in the pharmacy column annotate with the word ‘ward’. The second
checking nurse must document their name and their role (i.e. second-checking
Nurse) in the Additional Pharmacy Notes section.
5.2.8. When each drug has the pharmacy column filled in then click the ‘save change’
button at the bottom right hand of the screen.
5.2.9. Select ‘no’, to the clinical check section, dispensing and accuracy check and
‘Save changes’ as described above. This will sign the eDNF off. A copy must be
printed off and sent to pharmacy.
5.3 Where there is an urgent need to discharge patients due to a bed crisis (i.e. the hospital
bed status is Red or Deep Red), and all other avenues (stated above) to supply the
patients with discharge medicines have been explored, the on-call Pharmacist can be
contacted by the Senior Manager on-call and requested to dispense medicines needed
for discharge.
5.4 Before attending for a discharge prescription, the on-call Pharmacist will need verbal
assurance that all the discharge prescriptions/ eDNFs have been completed and signed
off as per eDNF/ Discharge Policy.
6 Urgently needed Medicines Information

6.1 Where urgently needed medicines information is needed that cannot be accessed
through the provided resources (e.g. BNF, cBNF, electronic Medicines Compendium,
UCL Handbook for the Administration of Intravenous Medicines), contact the on-call
Pharmacist
36

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DISPENSING AND STORAGE OF MEDICINES

THIS POLICY MUST BE READILY ACCESSIBLE AT ALL TIMES AND AT

The Medicines Management Group

Executive This policy provides guidance to all staff in East Cheshire

Supersedes: Version 2.0 Dispensing and Storage of Medicines Policy

This policy will impact on:

Policy Area: Medicines Document ECT002709

1.1 Policy Statement

1.1.2 The purpose of this policy is to:

 Provide guidance to all Trust staff on the procedures relating to

1.2.1 Medicines Management

Medicines Management in hospitals encompasses the entire way that

1.2.2 Registered Nurse

Throughout this policy a registered nurse is taken to mean any nurse,

1.3 Organisational Responsibilities

1.3.1 Chief Executive

1.3.2 Medical Director

1.3.3 Chair of Medicines Management Group

1.3.4 Chief Pharmacist

1.3.6 Ward / Department Managers

1.3.7 Pharmacy Staff

1.3.8 All staff

1.4 Planning and Implementation

East Cheshire NHS Trust recognises its responsibility to check practice in

Storage and security of There will be rolling audits to assess

A Medicines Management report will be submitted to the Trust SQS

It is the responsibility of the Medicines Management Group to review and

All staff groups involved in the management of medicines should receive

 All groups of staff involved in the management of medicines should

The objectives and contents of all in-house medicines management training

Training needs specifically tailored to individuals, or departments, may be

1.10 Dignity, Equality and Diversity

2. DISPENSING AND SUPPLY OF MEDICINES

2.1 Medicines Supply

2.1.2 It is not acceptable for staff to acquire medicines directly from

2.1.4 Medicines Supply – Ward Stock

“At risk medicines” – Diazepam/Codeine Phosphate/Co-codamol may only be

2.1.5 Medicines Supply – Non-Stock

2.2.3 A pharmacist or a trained pharmacy technician must assess patients’ own

2.2.5 Patients own medicines, to be administered by staff in the community should

 Visibly intact, clean packaging

2.3.2 All intravenous cytotoxic medicines will be dispensed in a ready-to-use form

2.3 Transport and receipt of medicines

2.4.1 Transport of Medicines in the Hospital

2.4.1.2 Where medicines need to be transported between wards and departments,

2.4.1.3 Medicines will normally be transported in security sealed transit bags or

2.4.1.7 All hospital discharge medicines must be received by a registered

2.4.1.9 Whenever possible, medicines should not be carried by health professionals

2.4.2 Transport of Medicines by Community Services Staff

2.4.2.2 Patients/carers should collect prescriptions themselves. Where this is not

2.4.2.4 In exceptional circumstances Health Care Professionals may carry Controlled

2.5 Supplying medicines for patients to use outside hospital

They can only be issued:

 From a pharmacy dispensed hospital discharge prescription (eDNF)

2.5.4 Supply of Hospital Discharge Medication:

Discharges requiring the pharmacy dispensary to complete the supply can

2.6 Supply of medicines to clinical areas when pharmacy is closed

2.6.1 Emergency Medicine Mediwell

2.6.1.1 Pharmacy provide access to Emergency Medicines out of hours via an

2.6.2.3 The Emergency Duty Pharmacist may advise:

2.6.3 Borrowing medicines

2.6.3.2 It is unacceptable to borrow controlled drugs from another clinical area,

In accordance with robust stock management, it is the responsibility of the